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Person-Centered Planning
Guide
February 2010
Table of Contents
Table of Contents ................................................................................................................ 2
Acknowledgments............................................................................................................... 2
Part I: Introduction ............................................................................................................. 3
Person-Centered Planning & Self-Determination ............................................................... 3
Person-Centered Thinking ........................................................................................... 3
“Person-Centered Thinking” Applied to Youths ......................................................... 3
Empowerment and Self-Determination ....................................................................... 3
Definitions and Principles of Self-Determination ....................................................... 3
Person-Centered Values ...................................................................................................... 5
Planning Timetable ............................................................................................................. 6
Person-Centered Planning Process ..................................................................................... 6
Building the Support Team .......................................................................................... 6
Conducting a Person-Centered Planning Meeting .............................................................. 7
Facilitating a Person-Centered Plan............................................................................. 8
Communicating within the Circle ................................................................................ 8
Supporting People Through Life Transitions ..................................................................... 9
Life Transition Resources ............................................................................................ 9
Part III: Person-Centered Career Planning ...................................................................... 10
Person-Centered Career Planning Process................................................................. 10
Person-Centered Career Plan Support Team ............................................................. 10
The support team: ...................................................................................................... 11
Person-Centered Career Planning Meeting....................................................................... 11
Career Planning Resources ........................................................................................ 12
PART III: Planning for Risk ............................................................................................ 13
Balance protection with self-determination ............................................................... 13
Risk Prevention.......................................................................................................... 13
Gathering Information ............................................................................................... 14
Sources of Risk Information ...................................................................................... 14
Observation ................................................................................................................ 14
Risk Management ............................................................................................................. 14
Key elements in developing risk management plan with the team ........................... 15
Risk-Management Resources .................................................................................... 15
Acknowledgments
Thank you to the following individuals for their efforts in revising these guidelines:
Jo Bryson Tammy Kief Cris Rodriguez Deb Wohlers
Tracy Connell Tracy Mauk Paulette Scheper Jennifer Wyble
Trina Cookson Jennifer O’Day Tish Thomas
Kyla Eversman Lorie Perdieu Darla Wilkerson
Randy Havens Teresa Rodgers Sandy Wise
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Part I: Introduction
Person-Centered Planning & Self-Determination
Person-Centered Thinking
Health philosophy has evolved from a medical model emphasis on a person’s long-term
disabilities, to a strengths-based focus on a person’s abilities and potential. Essentially,
“person-centered thinking” starts with the person and works outward, keeping that person
involved and in the center of all thinking and actions regarding personal services and
supports. One of the fundamental concepts within person-centered thinking is that of
understanding the balance between what is “Important to” and “Important for” the
person/family. What is “important to” a person/family includes only what the person or
family is saying with their words and with their behaviors. What is “important for”
people/families includes issues of health and safety, and how individuals can be valued
members of the community.
“Person-Centered Thinking” Applied to Youths
The person-centered approach to planning for young people depends on age and
development. Personal responsibility cannot be directly applied to all children and youth,
since children learn to assume responsibility to varying degrees as they grow and
develop. The family’s role also must be considered. When a child is living in a family
home, and self-determination is being addressed, the question is, “whose self-
determination are we talking about?” For instance, adolescents with developmental
disabilities may see adventure, new experiences, cars or sports as important to them,
while their parents may see safety, protection, and security as important for them.
Empowerment and Self-Determination
“Informed choice” implies that a person is empowered to determine how he or she wants
to live. Learning how to make informed choices involves educating individuals and their
personal advocates about their options. This process requires both time and professional
commitment in order to change how an individual’s needs are best met. The person-
centered process is highly individualized, and requires greater active participation from
the individual and family members than professionally-directed services. Yet as the
process develops, the initial educational investment is realized.
Definitions and Principles of Self-Determination
Self-determination: When individuals with developmental disabilities and their families
control the resources used to support them, their quality of life will improve and service
costs will diminish. This definition of self-determination stresses that “we cannot have
self-determination without people having greater control of their own lives and the
services and supports they need; this change in control must result in improvement of
opportunities and conditions experienced by the individual.”
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Freedom: People with disabilities will have the option of utilizing public dollars to build
a life rather than to purchase pre-determined programs. Freedom means that individuals
with disabilities, within a rational and cost-efficient system developed by stakeholders,
will be able to control resources through individual budgets. This will allow them to have
the necessary experience in living, and to move their dollars when their life choices
change.
Authority: Individuals with disabilities will have meaningful control over a capped
amount of dollars. Financial resources can be used to build needed supports by
purchasing only what is needed and paying only for what is received. When people with
disabilities need assistance in controlling dollars and planning their lives, those chosen to
assist in this process must ascertain the individual’s real desires and aspirations.
Support: Support is the opposite of “programming.” Through support, professionals
assist people with disabilities to nurture informal relationships with family and friends to
provide a support network. For people who currently do not have these natural resources
in place, creating this informal network will be important and yet presents challenges.
One of the underlying assumptions of this principle is simply that ordinary community
members, with education and under more natural circumstances and environments, will
welcome and support people with disabilities.
Responsibility: Like “freedom,” “responsibility” is a tenet in person-centered thinking.
People with disabilities can assume responsibility for giving back to their communities,
for seeking employment whenever possible, and for developing their unique gifts and
talents. Division of Developmental Disabilities professionals, both employed and
contracted, will support people as they assume personal responsibility.
Confirmation: The recognition that individuals with disabilities must be a major part of
the redesign of the human service system of long term care. “Having arrived” is when
the community doesn’t look at the disability, but at the potential.
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Part II: Overview of Person-Centered Planning
The Division of Developmental Disabilities requires that each person eligible for
Division services have a person-centered plan. This guide can be used by individuals,
their families, providers and facilitators, who write plans in cooperation with all persons
receiving supports and services from the Division. Person-centered planning encourages
an individual to involve personal and community networks in planning for the future. The
process involves developing a vision for the future, while coordinating resources and
supports to make the vision a reality.
The Center for Medicare and Medicaid Services (CMS) outcome for “participant-
centered service planning and delivery” clarifies: “Services and supports are planned and
effectively implemented in accordance with each participant’s unique needs, expressed
preferences and decisions concerning his/her life in the community.”
Person-centered quality outcomes are:
• Person-directed—Individual has the authority and is supported to
direct and manage his/her own services to the extent they wish.
• Assessment—Comprehensive information concerning each
individual’s preferences, personal needs, goals and abilities, health
status and other available supports gathered and used in developing
the personalized plan.
• Decision-making—Information and support available to help the
individual to make informed selections among service options.
• Free choice of provider—Assist the individual to freely choose
among qualified providers.
• Comprehensive plan—Addresses the individual’s need for services,
healthcare or other services in accordance with his/her expressed
preferences and goals).
Person-Centered Values
Division of Developmental Disabilities Quality Outcomes are defined by values that form
the foundation of a planning process:
• Person-centered planning supports personal authority and provides
meaningful options for individuals/families to express preferences, to
make informed choices, and to achieve hopes, goals and dreams.
• Person-centered planning discovers and understands what is
important to the individual/family and what is important for the
individual/family; and balances these viewpoints.
• Person-centered planning begins with strengths, gifts, skills and
contributions of each individual/family.
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• Person-centered planning is used as a framework for providing
services and supports designed to meet the unique needs of each
individual/family, while honoring goals and dreams.
• Person-centered planning is a process that enhances community
connections and natural supports, and encourages the involvement of
the individual/family in the community.
• Person-centered planning supports mutually respectful partnerships
between individuals/families and providers/professionals.
• The person-centered planning process respects culture, ethnicity,
religion and gender.
• Person-centered planning involves listening; action; being honest and
realistic; and discussing concerns about staying healthy and safe.
Planning Timetable
CMS-administered Home and Community Based programs require that each person
initially have a plan in place within 30 days of acceptance into the program. If the person
already has a person-centered plan, the plan must be amended within 30 days to reflect
any new services and supports that will be provided to the person upon entrance into the
waiver program.
Person-Centered Planning Process
The person-centered plan is a process involving as many people or agencies as needed to
achieve the desired outcomes for each individual. The plan belongs to the person.
• Person-centered planning helps people achieve their life goals.
• A person-centered plan evolves and changes as the person evolves
and changes.
Building the Support Team
Whenever possible, individuals should freely choose the members of their circle, who can
be:
• family members or guardians
• friends or peers
• direct support professionals (care givers, personal care attendant, etc.)
• other support professionals (service coordinator, case manager, social
worker etc.)
• whoever is involved in their lives
The planning team consists of
• an individual (focus person), and
• a circle of support (support team)
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A circle of support helps individuals develop their plans. Since the person-centered
planning team builds and sustains relationships, potential team members will have
community contacts, with support emphasis placed on naturally occurring relationships
and resources. Team members cooperate in solving problems and helping individuals
• attain their potential
• achieve life goals
• realize their dreams
Conducting a Person-Centered Planning Meeting
1. The focus person chooses
• time, date, place __________________________________________
• meeting topics __________________________________________
• facilitator
__________________________________________
• circle of support __________________________________________
• ________________________________________________________
____________________________
2. Prior to the meeting, each support team member spends time with the focus
person to learn more about his/her hopes, dreams and preferences.
3. When they meet, the focus person and support team members review the most
recent plan; discuss changes, updates and new goals; and make plans to
implement changes.
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Facilitating a Person-Centered Plan
The meeting facilitator may be a service coordinator or professional affiliated with
another agency or provider. The focus person has additional options, such as facilitating
the meeting him- or herself (with support if desired), or choosing an independent
facilitator—a friend, neighbor, family member, or someone trained as a person-centered
planning facilitator.
Since person-centered planning is about relationships, a facilitator either has a
relationship with the focus person, or establishes a relationship with the person prior to
the meeting. The facilitator’s ability to ask the right questions, and to communicate
directly with the focus person, will enhance the plan and its process. The facilitator’s
credibility with the person, community and service system will dramatically influence the
success of the planning process.
Choose a facilitator who has the following attributes—
• Team player; works well with others;
• Flexible and open-minded; does not make assumptions
• Person-centered and skilled at keeping the focus of the meeting on
the person
• Good listening skills and ability to interpret behavior as
communication
• Skilled at checking with the person
• Consistent, and experienced with follow-through
Communicating within the Circle
To support others in self-determination, team members must be experienced
in listening to and understanding a person’s communication style. All
communication is purposeful, and all people have a need to communicate.
Most people express ideas, feelings and desires through words, gestures and
body language to convey messages and respond to others. Some individuals
have difficulty communicating, and thus what may be perceived as
inappropriate behavior is often a person’s way of expressing feeling or
thought.
Communication requires a willingness to use all available means in order to
understand and to be understood (e.g., pictures, sign language, gestures, body
language, augmentative devices, etc.). At the planning meeting, alternative
methods for communication should always be available.
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Supporting People Through Life Transitions
Every individual experiences life changes or transitions. When the person’s life changes,
the plan changes in response. As a person develops, the plan evolves.
Examples of life transitions are:
• school graduation
• starting a new job
• changing jobs
• losing a job
• getting married
• having a baby
• getting divorced
• moving to a new home
• health issues (e.g., life-altering illness)
• onset of a disability (e.g., accident resulting in a brain injury)
When unexpected things happen, people often feel “derailed” or “off balance.” To help
the individual move forward after such life events occur, the planning team meets and
continues to adjust and modify the plan. While the circle of support is designed to carry
the individual through difficult transitions, there are times when professionals can offer
extra support—helping the individual revisit effective support strategies, and/or assisting
in the development of more effective strategies.
Life Transition Resources
For Person-Centered Plan Amendment and Quarterly Review, see _______
Service Coordinator’s Manual
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Part III: Person-Centered Career Planning
“The process must be empowering for the person in order to promote a variety of
possibilities.” (Institute for Community Inclusion, University of Massachusetts)
Person-centered career planning helps individuals reach their employment goals. The
Division of Developmental Disabilities vision states that employment is a viable option
for all people with developmental disabilities, and includes the following beliefs:
• People who want to work can work.
• People who are of working age are expected to work.
• People have the right to achieve their career goals.
• People should have prevailing wage; and
• People should have the opportunity to realize economic self-
sufficiency.
Person-centered career planning involves finding ways for an individual to contribute to
the community, and to earn an income that is consistent with the person’s interests, gifts,
talents and preferences. Person-centered career planning focuses on what is important to
the person.
Person-Centered Career Planning Process
The planning process involves a support team or circle of support selected and invited by
the individual (focus person) to assist in all phases. Team members serve as connections
to potential employers, and assist the individual in finding a job consistent with his or her
career goals.
The career-planning process involves challenges:
• Many people with disabilities have limited work, life or decision-
making experience, and thus defer to others.
• Some people have unrealistic ideas or goals about employment.
• The planning process embodies an ongoing commitment to discover
what is important for the person.
Person-Centered Career Plan Support Team
Individual job seekers direct their job searches, and select other individuals for assistance.
Pursuing a career, as well as getting and keeping a job, all require ongoing support. The
support team includes (but is not limited to) the job seeker, family, friends, employment
specialist and service coordinator. The job seeker and/or the team also may choose other
members to assist in the job search and make connections.
Members of the support team have a shared vision and value base consistent with the
Division of Developmental Disabilities vision: Anyone who wants to work can work.
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The critical work of the support team is to help the job seeker:
• Identify the kind of career/job the job seeker wants and desires;
• Identify businesses that employ people in the job seeker’s career/job
of choice;
• Identify businesses the job seeker would like to work for;
• Identify job openings for which the job seeker’s skills and knowledge
match the employer’s need(s);
• Schedule interviews for desired positions.
The support team:
• Supports the choices made by the job seeker.
• Utilizes natural support mechanisms as much as possible. Many of us
often obtain jobs because of whom we know.
• Accepts changes that naturally occur during the job/career
development.
Person-Centered Career Planning Meeting
Once the support team is chosen, the focus person schedules a meeting. At the planning
meeting, all person-centered planning components apply, and these identify:
• What is most important to and for the job seeker,
• What does and does not work or make sense in the person’s life,
• Necessary support strategies, and
• An action plan to assist in the job/career development, with specific
outcomes and strategies that makes sense to the person.
In order to understand what is important to and for the person, the support team gathers
information. The following questions can help the job seeker and support team develop a
plan or blueprint for employment possibilities.
• What are the person’s dreams?
• What are the things the person likes to do?
• What are the things the person likes least?
• What is the person’s routine and how are they supported?
• What is the person’s dream job?
• What work experience does the person have or had?
• How does the person learn best?
• What are the characteristics of the people who best support the
person?
• How does the person problem solve?
• How does the person ask for help or assistance?
• What accommodations are necessary in the community?
• What is the person’s work history?
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NOTE —
The Department of Mental Health, Division of Developmental Disabilities is a member
of the State Employment Leadership Network (SELN). As of March 2009, the Division
of Developmental Disabilities has a state employment work plan that summarized the
state’s goals and commitment to moving the employment initiative forward.
Career Planning Resources
• Missouri Career Network Participant Workbook
• A Guide to Person-Centered Planning for Job Seekers
http://www.onestops.info/article.php?article_id=189‚"cat_id=4#intro
• More Than Just A Job: Person-centered Career Planning, Institute for
Community Inclusion, online at:
http://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?article=136
7&context=gladnetcollect
• Show Me the Money: Flexible Funding for Job Success
http://www.communityinclusion.org/article.php?article_id=150Traini
ng Resource Network, Inc
• http://www.trninc.com/trn-
store/search_results.asp?txtsearchParamCat=2&txtsearchParamMan=
ALL&txtsearchParamVen=ALLL
• http://www.communityinclusion.org/
• www.worksupport.com
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PART III: Planning for Risk
Serious risks are actions likely to cause serious emotional or physical harm or death to an
individual or others. Risk is unique to each person’s individual circumstance: what is
threatening for one person may not be risky for another person.
Risk is complicated: It is an inter-related combination of:
• individual circumstances (things beyond the person’s control),
• personal actions/decisions (actions the person does to increase or
decrease the risk), and
• the person’s understanding of the cause and effect of his or her
actions.
Why do we think more consciously about risk in the lives of people with disabilities?
Often there is a concern that people with disabilities are not as able to understand the
complexities of everyday life. We may worry that those individuals do not understand the
consequences of their own actions, or the effect they may have on others. We may also
think that individuals with disabilities are unable to make independent judgments without
significant support; we see them as vulnerable, and we fear that some risk will lead to
serious injury or death.
In some cases these concerns may be valid. People with disabilities are four times more
likely to be at risk for violent victimization, abuse and neglect, than those without
disabilities. Studies estimate that close to 80% of women with DD have been sexually
assaulted at some point in their lives; this number is two to four times higher than for
people without disabilities. (Abuse and Neglect of Adults with Developmental
Disabilities: A public health priority for the State of California, August 2003) People with
disabilities share the same vulnerabilities as others, yet they may be less empowered to
overcome them, and may not know how to access the support they need. Some
individuals may not be able to understand risks and consequences. People with
disabilities may also experience a lack of access to health services and medical care and
may be considered at risk for various conditions (Rowe, Human Services Research
Institute 2008).
Balance protection with self-determination
The growing self-advocacy movement proclaims, “Nothing about me without me!”
Providers and planning teams may be concerned that they will be held liable if the
individual comes to harm or harms others, and may not honor the individual’s choices if
they think health/safety concerns present roadblocks.
Risk Prevention
Prevention of risk is an ongoing process… that starts with the person (Rowe, 2008,
Human Services Research Institute). Planners must first gather information about the
person’s history, hopes and dreams, affiliations and personal connections, ability to
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understand risk, and the personal rewards the person derives from risk-taking. Planners
need to understand the person’s ability to accept support in mitigating risk.
Gathering Information
To gain knowledge about the person, we must listen to the person and try to understand
his or her personal goals, and what he or she sees as most important in life. We gain
information on the person’s understanding of risk, including his or her level of
comprehension of negative outcomes. In gathering information it is important to talk to
key people; visit and observe the person in the environment where he or she lives, works
and plays; and in some situations, conduct formal assessments.
When gathering information and discussing risk: ask open-ended, non-directive
questions, avoid yes/no responses, and confirm responses with people who know the
individual.
Sources of Risk Information
Review of formal assessments can indicate risk factors, and potential areas of support.
Assessments may include:
• Comprehensive clinical assessment results
• Recent medical examinations (and recommendations), including
reports from specialists
• Reports from any recent hospitalizations
• Formal “risk screens or assessments”
Observation
Observing people in their own environments also can provide valuable information about
the individuals and their abilities in mitigating potential risk. For instance, check on:
• Accessibility
• Emergency evacuation
• Signs of negative interactions with caregivers
• Inability to communicate and to be understood
• Avoiding personal care
Risk Management
• First, talk to the person (and/or family/guardian). Communicate that
you are concerned about some things, and will be discussing some
risk issues.
• Review the risk issues that will be a part of the planning meeting.
• Assist the person in deciding who should be at the meeting, since a
large group can be fairly intimidating.
• Ascertain if there is someone the person does not want to be at the
meeting.
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Key elements in developing risk management plan with the team
• Arrive at consensus on which risk and safety issues are most critical
to address.
• Determine if the risk issues are seen by the person as important to
his/her quality of life.
• Discuss and consider what supports are already in place to
mitigate/reduce the risk.
• Make sure that all involved knows their roles and responsibilities
(including paid and non-paid supports).
• Determine if the outlined supports can be coordinated across service
environments.
• Develop a way to monitor the implementation of the
services/supports.
Risk-Management Resources
State Assessment Tools
• Arizona Prevention and Risk Assessment Tool.
http://www.hcbs.org/files/58/2894/AZ_prevention_risk_assessment.pdf
• Tennessee Risk Issues Identification Tool/Risk Analysis and Planning Tool.
http://tennessee.gov/dmrs/provider_agencies/planning_resource_manual/Appendi
ces/Appendix%20C2%20Risk%20Assesment%20Tool.pdf
• Rhode Island Safety/Risk Assessment Tool..
http://www.mhrh.ri.gov/ddd/pdf/DDDRiskAssessment.pdf
Risk Assessment Articles
• Listen, Learn, Act. Selected Writings by Michael W. Smull on Essential Lifestyle
Planning, Self-determination, and Organizational Change.
http://learningcommunity.us/documents/listenlearnact.pdf
• California’s DD Safety Net website: http://www.ddssafety.net/Main.aspx
• Person-centered Planning and Perversion Prevention, by Michael W. Smull and
Susan Burke Harrison. http://www.allenshea.com/perversion.html
• Person-Centered Planning-Building Partnerships and Supporting Choices,
California Developmental Disabilities Services. This publication consists of
excerpts taken from the Individual Program Plan Resource Manual to facilitate
consumers and their families regarding person-centered planning.
http://www.dds.ca.gov/publications/docs/Person_Ctrd_Planning.pdf
• The Origins of Person-Centered Planning - A Community of Practice Perspective,
by Connie Lyle O’Brien and John O’Brien. http://thechp.syr.edu/PCP_History.pdf
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Missouri Department of Mental Health
Division of Developmental Disabilities
1706 East Elm Street
Post Office Box 687
Jefferson City, MO 65102
PHONE: (573)751-4122
FAX: (573)751-8224
WEBSITE: www.dmh.mo.gov
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